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Case:Pickles
Introduction London, UK Pickles - 14 yr old spayed female. Weight 4.55kg. Taken on as a long-term foster from local cat rescue December 2005. Described as an "old broken diabetic cat needing a holiday in a nice home". Diet Pickles has a highly sensitive digestive tract due to an overactive immune system. Fish, beef, cereals, soya all cause her trouble. At rescue Royal Canin 'Sensitivity S/O' wet food, 100g (chicken and rice) and handful of dry James Wellbeloved. At home Immediately switched to 100% Felix in Jelly (low carb wet food) - no beef or fish flavours. Now eats 50:50 raw:tinned. Takes 1mg of budesonide SID with food (local acting steroid) to help keep localised gut lining inflamation under control. Does not affect BGs. Pickles had a heart murmur, grade 2 according to the rescue vets but private has never heard anything. Diabetes History. March 2005 - December 2005 Diagnosed diabetic March 2005 when admitted due to severe abcess on back right foot. Surrendered to rescue August 2005 due to owner's ill health. Diabetes history is limited. Spreadsheet lists insulins tried, BGs from diagnosis until leaving rescue to come to me: http://www.eel.homechoice.co.uk/Pickles's%20history.xls Diabetes December 2005 - October 2006. Thought to be insulin resistant having failed to stabilise on three insulins - Lente, PZI and Caninsulin. When taken from rescue was deemed 'stable' on Caninsulin 14 units twice a day (28 units a day), however not controlled. Vet said her 'normal' levels were between 20 - 25 (360 - 450). Pickles was put back on Insuvet PZI in January 2006. Pickles has proved very hard to regulate. Increasing doses of insulin needed to control BGs. Periods of normal BGs for a couple of days at a time requiring little support through insulin shots. For example: PS/+12 17.7 (319) --9.5 units PZI +4 --------13.7 (247) +5 --------12.8 (230) +6 --------13.3 (239) +7 --------12.7 (229) +11 ---------8.9 (160) PS/+12 -----8.9 (160) --1 units PZI +2 ---------8.7 (157) +4 ---------7.6 (137) +12 ---------2.6 (47) +14 ---------4.2 (76) +16 ---------5.5 (99) +18 ---------6.2 (112) PS/+20 ----10.3 (185) --1 units PZI +4 --------13.2 (238) +6 --------16.1 (290) PS/+7 -----17.2 (310) --5 units PZI Between January and September2006 insulin doses were gradually increased in an attempt to get some downward movement of BGs. Short acting Insuvet Neutral was introduced in the hopes of gaining better control of the diabetes. Investingations at the vets resulted in a negative Cushings test, blood panel all within normal limits, abdominal ultrasound showing no fluid in her pot-belly just abnormal fat deposits. Clear for FIV, FeLV but with two maximum titres for feline corona virus (end of Feb, begining of May). **June 2006** Severe foul smelling vomit. Vet visit and emergency surgery. Pickles had a large intussusception (when the bowel slides in on itself like a telescope). The vets managed to untangle/straighten it and there was no tissue damage. Unfortunately there was a nodule in the lumen of the small bowel right in the middle of the affected section of gut. The vets had to resect her bowel, removing a 2 cm section of gut and sew things back together. They also found another 3 nodules further down the gut in different places. The two smallest ones were about 3-4 mm across and were biopsied. They took out the larger of the three. All biopsies came back 'cancer free'. The report said that overgrowing epithelial cells pushing through the mucosa due to either excess bacterial growth or localised autoimmune response caused the lumps that caused the intussusception. Takes 1mg of budesonide SID with food (local acting steroid) to help keep localised gut lining inflamation under control. Does not affect BGs. Pickles recovered quickly from her surgery. **July 2006** 1st July started Tight Regulation with Pickles. Please see 'Pickles's Numbers' on the Testing Forum at Your Diabetic Cat ( http://www.yourdiabeticcat.com/forums/default.asp ) **August/September 2006** Considering the possibility that Pickles has immune mediated insulin resistance. Possibly Cyclosporin could be used to depress the immune system to see if this will increase insulin action. Decided to wait for results of IGF-1 test (see below). Pickles up to 120 units of PZI and 45 units of N per 24 hours with varying BG levels. The Royal Veterinary College, UK running an acromegaly trial for diabetic cats. http://www.rvc.ac.uk/Hospitals/QMH/Referrals/ClinicalTrials/Medicine.cfm#acro The testing for the IGF-1 is free requiring your vet to take specific samples of blood from one visit to the surgery. **October 2006** Pickles confirmed as having Acromegaly (a tumour on her Pituitary Gland in the brain). Result was 1954 ng/ml IGF-1. Normal value is below 1000ng/ml. Pickles does not have the bone structure changes most vets expect to see in acromeglaic cats. She does however have insulin resistance, pot-belly and her weight has remained stable despite being an unregulated diabetic (a classic 'red flag' for acromegaly). Contorary to popular belief Pickles has had ketones, something many vets think is not possible in acromegalic cats. Radiotherapy is not an option. Oral medications are not successful in cats however I am in the process of working with the RVC and Pfizer to see if a realtively new human drug might be transferable to cats. Somavert acts systemically competing with the IGF-1 resulting in normal IGF-1 levels in humans. The resultsing drop in IGF-1 levels allows for a return to normal BGs in human patients. The main problem with this treatment is that one months treatment for a human is approximately £1500. CT Scan confirmed IGF-1 blood test results. Pickles's pituitary gland is twice the size of normal. The diagnosis of acaromegaly explains the fluctuations in Pickles's blood sugars and the need for large amounts of insulin. With acromegaly in cats caused by a Growth Hormone (GH) secreting pituitary tumour it's not the size of the tumour so much as it's makeup. The problem is that some of the cells in the tumour produce GH but not all of them. The exact proportions of 'good' and 'bad' cells vary in each cat. So there is the potential for some cats not to be badly affected with the resulting diabetes because there are not many GH producing cells in their tumour, even if the tumour itself is huge. Conversely you can have a cat with a very small tumour that happens to be made up of a large proportion of GH secreting cells and as a result has very bad diabetes. Add in another factor. The pituitary gland does not put out all of it's hormones all the time, obviously. So pituitary function waxes and wanes. That waxing and waning can, in some cats, influence the tumour cells that kick out the GH. In some cats those cells produce the GH all the time, not being influenced by the pituitary gland but in others, like Pickles the GH levels being kicked out flucutate. If the GH levels fluctuate then so does the resulting diabetes. Hence Pickles's ability to run in normal numbers - no excess GH in the system then no diabetes. This was what kept the vet off the trail of acromegaly, her ability to be 'normal'. It also drove me crazy not understanding what I was 'doing wrong' when I couldn't get her numbers 'back down'. It wasn't anything I was doing, it was all about the changes in GH levels. Eventually with acromegaly the tumour can get so big it starts to affect the cat neurologically, and some cats never really have problems with the diabetes, it's the neurological symptoms that are the problem. Tumour size doesn't necessarily relate to neurological impairment. The vet at the Royal Vet College here (who is doing the study into acromegaly in cats) said that she's seen cats with no signs of neurological disturbance but with huge tumours and some cats who are badly affected and yet their tumours were tiny. Examples of GH fluctuation and the resulting BGs in Pickles: PS/+13 ----17.3 (311) -- 12 units PZI PS/+11.5 ---8.9 (160) -- 3 units PZI +9 ---------6.6 (119) +12 --------4.4 (79) +16 --------11.2 (202) -- 5 units PZI PS/+8 ------17.4 (313) -- 10 units PZI +5 ---------16.9 (304) PS/+13.5 ----17.1 (308) -- 12 units PZI --------------- PS/+6 ----21.2 (382) -- 24 units PZI PS/+6 ----9.8 (176) -- 1 units PZI PS/+12 ---25.8 (464) -- 13 units PZI At the end of September 2005 Pickles's BGs suddenly became even less responsive to insulin with the fluctuations in the GH becoming less frequent or significant. The vet at the RVC thinks that this is an indication that the number of GH secreting cells in the tumour have increased in quantity over a threshold where GH levels are consistantly high. I am now at the stage where I have found a dosing amount and frequency that prevents Pickles's BGs from rising but I can no longer lower them - 15 units of PZI and 10 units N BID. If mid-cycle she throws a higher than normal BG a shot of 10 units N normally brings her back to her basic BG level of ~20 (350). I tried Pickles on Levemir. This insulin gave very good predictable durations. However, it did not help with lowering Pickles's BGs and due to costs I returned to Insuvet PZI. Had money not been an issue I would have continued with the Levemir. Pickles still has a wonderful life, despite the high BGs. Understandably not being able to control her BGs will have a negative impact on her organs, coupled with the effects of the excess GH and IGF-1 her body is under strain. However, there is no hard and fast rule as to how long she has. Category:Female cases Category:Feline cases Category:Oral med casesCategory:Humulin L cases Category:Levemir cases Category:Insuvet PZI cases Category:Caninsulin cases Category:Booster casesCategory:Difficult regulation cases Category:low-carb cases Category:Neuropathy cases Category:Ketoacidosis cases Category:UTI cases Category:Other infection cases Category:Bowel cases Category:Tight Regulation casesCategory:Overlap cases Category:Acromegaly casesCategory:Feline Levemir users